Form A - CERTIFICATION FORM - LAND APPLICATION
July 1, 2014
Instructions:
1. Each form must be signed and dated to be valid.
2. The certifier shall print or type his name below the signature line and print or type the certifier's title, if any, where indicated.
3. When the certifier checks a box or fills in a line other than the signature or date lines, the certifier shall initial below the check or the line, unless the certifier uses preprinted versions of the form which delete the boxes and lines which must be initialed.
[ ] For preparers only, I certify, under penalty of law, that:
[ ] 1. The pollutant concentration ceiling limits in Table IV of chapter 11-62, HAR have been met.
[ ] 2. The following pathogen requirements have been met:
[ ] a. The Class A pathogen requirements of § 11-62-46(a), HAR, specifically § 11-62-46(3) (_____); or
[ ] b. The Class B pathogen requirements of 40 CFR §503.32(b), specifically §503.32 (b) (______) and notification each land owner and land applier of wastewater sludge which I have prepared, of the spacing and site restrictions in § 11-62-43(g), HAR; and the management requirements in § 11-62-43(h), HAR.
[ ] 3. Vector attraction reduction:
[ ] a. One of the vector attraction reduction requirements in 40 CFR § 503.33(b) (1) through (8), has been met, specifically §503.33(b) (___); or
[ ] b. I have not met the one of the requirements of 40 CFR § 503.33(b) (1) through (b) (8), and I informed the land applier and the owner of the land application site that one of the vector attraction reduction requirements in 40 CFR § 503.33(b) (9) or (b) (10) must be met;
[ ] For appliers of wastewater sludge only, I certify, under penalty of law, that:
[ ] 4. One of the vector attraction reduction requirements in 40 CFR § 503.33(b) (9) or (b) (10) has been met, specifically §503.33(b) (____);
[ ] 5. The spacing and site restrictions in § 11-62-43(g) have been met; and
[ ] 6. The management requirements in § 11-62-43(h), HAR have been met.
[ ] For appliers of septage only, I certify, under penalty of law, that:
[ ] 7. One of the pathogen requirements in 40 CFR § 503.32(c) (1) or (c) (2) has been met, specifically §503.32(c) (____);
[ ] 8, One of the vector attraction reduction requirements in 40 CFR § 503.33(b) (9), (b) (10), or (b) (12) has been met, specifically §503.33(b) (____);
[ ] 9. The spacing and site restrictions in § 11-62-44(g), HAR have been met; and
[ ] 10, The management requirements in § 11-62-44(h), HAR have been met.
I certify, under penalty of law, that the information that will be used to determine compliance with the foregoing requirements was prepared under my direction and supervision in accordance with the system designed to ensure that qualified personnel properly gather and evaluate this information. I am aware that there are significant penalties for false certification including the possibility of fine and imprisonment.
Date_________________________ Name_______________________
Title:______________________